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Can Erel

“Launch and Development of Air Ambulance Services in Turkey”

Issue 4 - 2020
“Launch and Development of Air Ambulance Services in Turkey”

In this issue, we are proud to share a part of the “CAN’CA Interview” by Can Erel, Chief Advisor to the Aviation Turkey Editorial Board with Dr. Mustafa Şevki Ataç, MARM Assistance Board Member, about his career related to the first air ambulance services in Turkey. 

During the initial period of my forty-year professional life after I had engaged in military aviation, I dealt with the trade of air ambulances, including providing instruction on how to quickly transform air vehicles into air ambulances that could serve as an intensive care unit and which even provide medical procedures during flight. 

This year, the Women of Aviation Worldwide Week theme "Women with Wings Healing the World" was chosen by the Institute for Women of Aviation Worldwide, based in Montreal, Canada, to celebrate 85 years of female flight paramedics.

This theme reminded me of the First Turkish Female Doctor and the First Turkish Female Nurse assigned in the flight health crew, as well as the First Turkish Female Pilot of the fixed-wing emergency medical services aircraft (EMS) and the First Turkish Female Pilot of the rotary-wing air ambulance (helicopter emergency medical services - HEMS). To that end, I decided to learn more about such details from a senior member of aviation and receive his opinions on the subject. He had offered that I manage his company, and I am honored by his request even though we could not make it happen at the time.

And then the COVID-19 pandemic and the fight against it started. Therefore, since it is one of the issues - perhaps the most critical one - that connect aviation and healthcare, it was certainly due time to start the first stage of the series of the “CAN’CA Interview” that delves into the subject of the launch and development of air ambulance services in Turkey, the milestones of these ambulance flights conducted with fixed-wing air vehicles (EMS) and rotary wing air vehicles (HEMS), the transported patients, flight and health crew. I finally managed to reach Dr. Mustafa Şevki Ataç and though he has been away from detailed sources regarding this subject, he positively replied to my sincere suggestion for an interview with his friendly and constructive manner as usual. So, I carried out a video conference within the scope of the hashtag #stayathome, and we were able to discuss this topic with the benefits of modern technology.  I would like to share a part of this important interview with the esteemed readers of the Aviation Turkey Magazine. 

Can Erel (CE): Who is Dr. Mustafa Şevki Ataç, where and how did his childhood and youth pass?

Dr. Mustafa Şevki Ataç (Dr. MŞA): I was born on April 24, 1947 in Ankara, the first of four children. My father was a former member of the Turkish Armed Forces and my mother was a housewife. I was raised by my grandparents till I was 10 due to my father’s compulsory service in the East. I went to TED Ankara College for elementary and high school and then completed my graduate degree at the Faculty of Medicine at Ankara University. 

CE: How did you become interested in medicine, please tell us about your achievements as a medical doctor? 

Dr. MŞA: Upon my graduation from the Faculty of Medicine at Ankara University, I went to the Netherlands. I worked as a general practitioner in the eastern part of the Netherlands densely populated by Turkish employees. Examination clinics where I was able to examine Turkish and other foreign patients were established at eight different locations within six months. 

Upon the arrival of two of my beloved classmates to the Netherlands, we started to offer the best healthcare services we could to Turkish patients.

As a result of the aforementioned efforts, for the first time in the history of the Ministry of Health, Welfare and Sport in the Netherlands, a foreign doctor had been authorized to open a clinic. 

The most striking point during this project was the close attention of the Dutch authorities and their willingness to consult us especially on the healthcare and social issues regarding foreigners. 

Netherlands placed significance importance on science and technology and directed this focus towards creating an impressive education system, and now the Netherlands is recognized as a top country in the world in terms of their successful education system. I aimed to specialize in a major department of medicine in which the Netherlands had advanced and then return to Turkey and serve my country which enabled me to be trained in such an expensive branch of medicine. Such an opportunity emerged upon my acceptance as an assistant to the Neurosurgery Department of the world-renowned Erasmus University’s Faculty of Medicine in Rotterdam. 

After I completed my specialization, I left the Netherlands where I worked with great will and desire and where I received utmost warmth and returned to Turkey with my wife and two children. 

I worked at the Faculty of Medicine of Ege University for nearly two years and then started to work at Izmir State Hospital as an Assistant to the Director. I started to operate being thankful to the Governor of the city who soundly invested the financial aid granted by the Queen of Britain during the Crimean War in the establishment of a hospital at the Konak district of Izmir. I could never forget the team at Izmir State Hospital who worked selflessly, without ever complaining about working uninterruptedly, night and day. 

During my specialization in the Netherlands, I coincided with a single patient with a bullet in the head, yet I had to respond to many bullet injuries in the head and spine during the period before September 12, 1980 (date of military coup). In those days, Ege University and the newly founded Dokuz Eylül University with limited facilities were transferring patients with bullet injuries to the State Hospital as the injuries had “political” motives. Due to the limited number of assistant doctors, I collaborated with the assistants I had requested from the clinics of orthopedics and ophthalmology in rotations of three months. I barely went home most of the time; those who did not experience the era of September 12 would never know the hardship we went through! 

One of the issues that concerned me most was the loss of lives caused by the deficiencies in the patient transport system (ambulances) as we lost patients that could have been resuscitated merely through practical responses, after road and occupational accidents. The second issue was that the number of patients transferred from hospitals with limited facilities to hospitals offering superior healthcare services was so low that barely any patients had that opportunity! 

The ambulances of the Provincial Health Directorate were extremely insufficient, and they were used to carry the loads and equipment in addition to patients! The problem with the transportation of patients had to be solved! But how?

Turkey made incredible progress in tourism in the midst of 1980s. Amazing facilities were built in a short amount of time and the highly capable Turkish people had the opportunity to get acquainted with tourism and loved it, but the healthcare services lagged behind in the touristic regions that had developed rapidly. There was nothing that the state administration could do about it. The medical doctors and businessmen initially established clinics and then their hospitals in these regions where seasonal operations took place. Yet they had very limited facilities! 

Most of the air ambulance companies established abroad took advantage of the limited healthcare services offered in touristic regions in countries such as Turkey and they rapidly developed. Why could we do nothing but witness such developments and how had we failed to take any action?

In 1986, with the help of MARM Assistance, which I had established as a result of certain coincidences, we started to offer healthcare services to foreign patients. We enabled their access to proper healthcare institutions so that they could receive appropriate services from proper medical doctors at convenient prices at the right time, and as a result the business grew quite big very soon!

In those days, the healthcare services in major Turkish cities such as Ankara, Istanbul, Izmir and Adana were more advanced compared to other cities in the country. I could do nothing but watch with sorrow as patients were taken to their own countries via air ambulances because they could not be treated at the local hospitals. It was apparent that the promotion of “Turkish Healthcare Services,” and increasing Turkey’s prestige and attracting foreign patients to Turkey could be achieved and maintained through proper patient transportation services. 

Something had to be done! 

CE: How did you focus on air ambulance services? To be more precise, could you inform us on the establishment of the first company, namely MARM, to offer air ambulance services in Turkey with an operation license dated 29.09.1998 and numbered 49 as per the Turkish Civil Aviation Law no 2920? 

Dr. MŞA: Turkey is really a wonderful country! At the same time, it is situated in a large geographical location rendering it inconvenient for land transport, particularly in the transport of patients. Transporting a patient from Alanya or Ürgüp to Ankara, to Izmir from Denizli or Uşak with a ground ambulance would bear great risks. The establishment of an air ambulance system in Turkey through the inspiration that could be drawn upon from the best practices in Europe that render these types of services with the same quality should have been an objective for Turkey as well.

Wings Aviation, as an air ambulance company, was founded with a Beechcraft KingAir 200 aircraft equipped fully with intensive care components and with the doctors and nurses of the intensive care unit of Innsbruck University, yet it was held back by the Tyrolian Air Ambulance company - an affiliate of Swarovski!

On the other hand, MARM Assistance was quickly recognized and accepted by foreign countries thanks to the services offered to foreigners across Turkey. The owners of Wings Aviation visited our center in Izmir at that time and asked if they could run the aircraft in Turkey by registering it in Turkey.

Well, this was unexpected! 

I told them that I was unfamiliar with the physiology of medical aviation, that flight doctors were merely employed by the Air Forces in Turkey and added that I had no experience in this area as I had never flown on a small plane in my life. The owners of Wings Aviation told me that they would be solving all those issues and asked me how many transports of patients I would be able to guarantee them per year. I replied to them by making the “zero” sign with my fingers, while inside I was telling myself “you did your best to miss this opportunity Mustafa” …Then again, honesty won as usual and we made a deal!

That was the first time I heard the title Directorate General of Civil Aviation (DGCA)! 

The management of the DGCA supported me in an unforgettable way and the TC-FBZ with Turkish registration was launched to service on September 29, 1989 as an aircraft (under the auspices of MARM Assistance with the operation license no 49) fully equipped with intensive care components that would not operate for purposes other than the transport of patients, for the first time in the history of the Republic of Turkey!  (Obtaining AOC from the Turkish Ministry of Health -1989)

I always remember the employees of the DGCA of that time with deep gratitude.

We not only transported patients from Turkey to their countries but also foreign patients in Greece, Italy and the Balkans to their countries with this business. Furthermore, many patients were transported to Izmir from hospitals with limited facilities in the Greek Islands!

In the meantime, the Turkish medical team received fruitful training and the Austrian paramedics returned to their country after the third week of the launch of the business. Upon the joining of our first Turkish pilot, captain Yavuz Hünkar after two months and joining of captain Tayyar Ülker in the third month, the ambulance aircraft in the skies indeed became “Turkish”. Dr. Ediz Ural, twin doctors Dr. Yavuz Bilgin and Dr. Selim Bilgin became skilled flight doctors. 

In those days, there were only five countries in Europe that had their own ambulance businesses with air vehicles solely dedicated to ambulance services equipped with intensive care units. 

Wings Aviation received way more than it expected with the 139 flights conducted in 1989.

Turkish people would achieve everything with little support! 

At the beginning of 1990, we transported an unconscious Dutch patient with major head trauma with mechanical ventilation, also with pneumothorax and arm fracture, to Amsterdam with a young doctor from our team. We faced an unfavorable headwind during the flight and were able to land in Schiphol after a 7-hour flight. I was in a cold sweat during this transport due to intense and stressful work involved. On our way back, in Innsbruck, I recommended never to use the KA200 aircraft for long flights and suggested that a faster aircraft for higher altitudes should be purchased. 

Six weeks after my suggestion, the TC-EME Lear 35 aircraft equipped with intensive care components was launched to operation once again with the support of all DGCA employees!

I could never forget; the maiden flight of this aircraft was to Denver, Colorado, USA, with a completely Turkish team… 

We really achieved incredibly successful operations in those days! Among these, I should mention the patients we transferred to hospitals that had advanced treatment capacities from the hospitals with limited capabilities in Turkey! 

CE: How did the air ambulance services that were launched with MARM Assistance turn into Redstar Aviation Inc.? Would you like to share the developments you experienced along the way during that period?

Dr. MŞA:  A while after the start of Gulf War, an extremely unjust and improper sanction was imposed on Turkey in the field of aviation. Turkish airspace and all Turkish aircraft were obliged to have “war risk insurance”! This implied the payment of a war insurance that costed five thousand US Dollars even for short distance flights, and this type of insurances was only provided by global companies abroad.

In brief, the aviation companies in Turkey were officially being ripped off and unfortunately many of our aviation companies went bankruptcy in those days!

Explaining the war risk premium to patients’ relatives or to insurance companies was very difficult. Tourism activities were halted due to the war that would last for an uncertain amount of time and we were struggling to cope with the damages it caused Turkey.

In the end, after resisting for two months, unfortunately we had to terminate this exceptional service due to a war triggered by the US in our region! 

Months after, in late 1991, as I was told about the wish of Konstantin Mirechnichenko, who initially spoke to my assistant, stating that he was Aeroflot’s Director to Turkey, and he was asking to talk with me about the establishment of an air ambulance company with our company and I thought  to myself  “perhaps I am hearing this wrong…”, I asked him, “OK, so who will be the partner of MARM Assistance?” I was astonished to hear his answer, “Aeroflot”! I warned him on the assets we had at that time and for a moment I thought to myself whether I should direct Konstantin to bigger companies… 

Then we rolled up our sleeves and applied to the Undersecretariat of Treasury, the Foreign Capital Department of the State Planning Organization; their executives welcomed us warmly and guided us. See what one could achieve when supported and guided by the state! 

After the intense traffic between Rostov and Izmir that lasted nearly a year due to striking interpretation differences in terms of social, cultural and economic aspects, Aeroflot Company agreed to place four Mi-2 helicopters as capital in kind. We went through a very intensive work schedule for the preparation of all documents, the preparation of the company’s founding charter in both Turkish and Russian and its authentication in both countries and for the fulfilment of all rules set by the Undersecretariat of Treasury.

The staff of the DGCA changed, yet their notion of supporting well operated companies remained! Finally, in 1992, Redstar Aviation was established. All the processes were completed swiftly and TC-EGE, TC-TIP, TC- MED and TC-BBJ helicopters started to operate with all avionics of Bendix King Silver Crown and with intensive care components.

In the first years, in addition to Russian pilots and technicians, we collaborated with Turkish navigation pilots to avoid any problems in communication with the control tower. Then the Russian and Bulgarian pilots who obtained Turkish licenses by passing the exams started to fly as single pilots as they knew Turkish. By the way, I cherish and remember our Bulgarian pilots Captain Dimitr Laskin, Captain Julian Bogoey and Captain Sasho Mazaev with respect for their services and contributions. 

I owe Captain Ibrahim Orazlı and Captain Şaban Mollaoğlu, who contributed greatly to Redstar Aviation and exerted great efforts for the adaptation of foreign pilots, a debt of gratitude during our navigation period. 

I had the opportunity to witness the superior capabilities and virtues of Turkish pilots during the operations of Redstar Aviation through my excellent colleagues Captain Nihat Yılmaz and Captain Ali Ibanoğlu. They are enshrined in my memory with the outstanding services they provided.

In those days, the demand for a flight doctor in the operations of Redstar Aviation was fulfilled by the doctors of MARM Assistance. As we obtained the Private Ambulance Operating License in 1994, dear Reyhan Buruncuk who is “Turkey’s First Female Flight Nurse” made her mark by achieving the longest and hardest tasks. She lingers in our memories as an extraordinary person indeed.

It would be appropriate here to recall a few of the services provided by Redstar Aviation. 

During the second Gulf War, Redstar Aviation transferred US citizens evacuated from Iraq initially to Turkey and after their treatment or through operation “wing to wing” in Istanbul secured their return to their country via airplanes arriving from the US.  This is why we worked with two US pilots in our Jetstream 32EP ambulance aircraft for a long period of time.

Although no military staff was transported on these flights, the evacuation of civilian Americans was held under the supervision of US military staff, as it seen in a photo by a CNBC television reporter published in a newspaper during that time.

Another interesting operation we conducted was our service regarding Formula 1 races held in Istanbul for 7 years. The air ambulance services via helicopters at Formula 1 races were provided by Redstar Aviation. Also, the transport services for certain VIP guests to the racetracks were carried out by our company as well.

Furthermore, the practices regarding all relevant EASA and HAI rules concerning the ambulance services with helicopters provided by Redstar Aviation were held biweekly, or once every month in case of busy schedule.

Scenarios such as the transport of a patient picked up by a helicopter under appropriate conditions and procedures via aircraft in long distance flights in pandemics were also executed in order to remain prepared at all times. 

CE: Could you tell us about the air ambulance services conducted under the RedStar Aviation brand, particularly the operations held during the Earthquake in 1999? 

Dr. MŞA: The transportation of patients from hospitals with limited facilities to developed healthcare centers located in Ankara, Istanbul and Izmir made great progress in Turkey. The problem we faced in these operations was that even though four helicopters failed to suffice in the six-month period covering the summer season, one helicopter was more than enough during the winter. We were simply working during the summer to save for the winter! In the meantime, we were inviting flight doctors from the leading helicopter emergency medical service businesses in Europe, such as SAMU, DRF and NL for a while by covering their accommodation and allowances for maintaining the continuous training of our healthcare team at MARM Assistance.

Since its establishment, Redstar Aviation took part in natural disaster services without expecting any profit and operated in line with a certain mission.

During the Earthquake of 1999 in the Marmara Region, by collaborating with doctors from MARM Assistance and with three helicopters and two ground ambulances, we picked up patients with “crush syndrome” whose tissues were either partly or completely crushed or  patients who had been exposed to compression from falling objects from healthcare tents or local hospitals and then transported them initially to the intensive care units of hospitals in Istanbul, Ankara or Bursa.

These patients were generally rescued from wreckage and since they had crushed limbs, they did not show any symptoms during the first hours, yet they were lost due to respiratory or circulatory failure.

The roads were damaged due to the earthquake and this led to heavy traffic, so we sent the ground ambulances back to Izmir and continued to perform our operations with air ambulances. We saved 108 patients in this way! This should be perceived as a huge success when we look at the recent number of lost patients with unknown causes of death during the earthquakes in Van and Elazığ. 

Additionally, Redstar Aviation provided great support to Turkish paramedics exposed to the risk of “burn out” with the doctors from DRF, SAMU and Dutch doctors! This multinational healthcare team displayed incredible solidarity. As a result, during the “Helicopter Association International (HAI) Congress” held in 2000 with the support of a total of 11 countries and organizations such as the WHO, INSARAG and UNDP, Redstar Aviation received the “Igor I. Sikorsky Award for Humanitarian Service”. In this way, this award which has been granted since1948, was proudly received by a Turkish helicopter emergency medical services business - Redstar Aviation.  

But something was missing! 

I kindly asked the organization to grant the same award to the Turkish Land Forces Command that worked devotedly while supporting Redstar Aviation in terms of fuel replenishment and accommodation while facing problems due to the lack of harmony between the civilian and military staff. I requested from the HAI President at that time, Matt Zuccharo, to grant an award to the Land Forces Command stating that the civilian company Redstar Aviation achieved its tasks on account of the collaboration of this military aviation institution. My suggestion was not rejected and I delivered the award I received on behalf of them to the Land Forces Command in person in Ankara. It was unusual to grant the “Igor Sikorsky Humanitarian Aid Award” to military institutions. So once and for all, this award was received by a military force.

I should also mention that Redstar Aviation Inc. qualified for the ISO 9001:2000 Quality Management System in 2003 as well. 

CE: Could you share with our readers the most interesting anecdote regarding air ambulance services conducted by the Redstar Aviation brand during the Earthquake of 1999? 

Dr. MŞA: We have incredible memories. As Redstar Aviation, we not only performed operations for the Izmit and Düzce earthquakes in 1999, but also for the earthquakes in Adana, Afyon - Dinar and Milas. I have many anecdotes; let me mention an interesting one.

We transported a woman and a man with “crush syndrome” to the German Hospital in Istanbul; we transferred a child to Başkent University Hospital in Ankara and another child to the Hospital of Uludağ University in Bursa… The identities of the patients and their information were registered at the Medical Center of MARM Assistance that operated 24/7. All four patients were aided by respiratory devices and were being monitored. First, the female patient recovered and the device was removed. After seeing her husband being treated in intensive care, her question was “…what happened to my children?” MARM Assistance Dispatchers identified that the surnames of the two children who were under treatment at Bursa Uludağ and Ankara Başkent University hospitals were the same as that of the female patient and her husband. The next day, the child in Bursa was removed from the respiratory device, so we took him from Bursa to the German Hospital in Istanbul. With support from respiratory devices, we transferred the other girl from Ankara Başkent University Hospital to Istanbul as well. She was also removed from the respiratory devices and survived.  Words fail to describe the happiness felt at the reunion of the family when each member regained their health…

Witnessing this operation while contributing to it, Dr. Eelco Dijkstra later shared it with the reporters of British Daily Mirror and Dutch Algemene Dagblad and these newspapers published it! I refrained from asking for a copy in order to avoid any misunderstandings in such turmoil!

CE: The air ambulance services that were launched as part of a private enterprise and then sustained by Redstar Aviation Inc. were diversified and extended across the country after 2006 as services also provided by the Ministry of Health. What was your role in this process?

Dr. MŞA: We launched the notion of maintaining air ambulance systems by the state through “service procurement” first during the operations of MARM Assistance and in the following years, we sustained this system as Redstar Aviation Inc. By the way, believe me even I do not remember the number of workshops and meetings I attended at the Ministry of Health!

As Redstar Aviation we collaborated with various public institutions on limited projects.

The work scope of Redstar Aviation Inc. and the Ministry of Health in air ambulance services was quite different. The greatest leaps in healthcare tourism in Turkey were achieved by Redstar Aviation Inc. with the transfer of patients from regions with limited facilities to hospitals with advanced treatment capacities. Comments from foreigners such as  “I received excellent treatment in Turkey” were recognized as positive feedback for promotion. 

CE: Thank you for all your assessments that you’ve shared…Thank you! May you live long! 

“Certain moments require sharing; and certain people turn those moments into memories!” I would like to share this statement that I recalled during my interview with Mustafa Şevki Ataç.

It`s been my own pleasure to meet and know Dr. Mustafa Şevki Ataç; may he live in health and peace… We are lucky to have the establishment of this company in Turkey, Redstar Aviation Inc. May it fly safe and secure!  

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